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 ~ Case Report
 ~ Discussion
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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 307-310
 

An unusual case of lung abscess caused by Acremonium species treated with itraconazole


1 Department of Microbiology, Government Medical College, Nagpur, Maharashtra, India
2 Department of Tuberculosis and Chest Medicine, Government Medical College, Nagpur, Maharashtra, India

Date of Submission16-Jul-2014
Date of Acceptance13-Jan-2015
Date of Web Publication10-Apr-2015

Correspondence Address:
M S Qazi
Department of Microbiology, Government Medical College, Nagpur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.154893

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 ~ Abstract 

We present a report of a 37-year-old female with lung abscess due to Acremonium species that responded to oral itraconazole. There was a marked clinical as well as radiological improvement in patient. To the best of our knowledge, this is the first case of lung abscess due to Acremonium species which was treated by oral itraconazole. This cost-effective treatment modality proved to be significant in improving symptoms as well as morbidity in this patient.


Keywords: Acremonium species, itraconazole, lung abscess


How to cite this article:
Qazi M S, Bowalekar S S, Wanjare V S, Shankar A. An unusual case of lung abscess caused by Acremonium species treated with itraconazole. Indian J Med Microbiol 2015;33:307-10

How to cite this URL:
Qazi M S, Bowalekar S S, Wanjare V S, Shankar A. An unusual case of lung abscess caused by Acremonium species treated with itraconazole. Indian J Med Microbiol [serial online] 2015 [cited 2019 Dec 12];33:307-10. Available from: http://www.ijmm.org/text.asp?2015/33/2/307/154893



 ~ Case Report Top


A 37-year-old female was admitted to department of chest medicine and tuberculosis on 23 rd October 2013 with complaints of chest pain and cough of 15-days and breathlessness of 7-days duration. There was no significant past medical/surgical history pertaining to tuberculosis, diabetes mellitus, hypertension and bronchial asthma.

On examination, patient was febrile, well-oriented; blood pressure (BP) was 110/60 mm of Hg.

Major systemic involvement was unremarkable except for presence of right basal crepitations, with equal bilateral air entry. Chest wall was symmetrical with no obvious deformity.

Chest X-ray was suggestive of thick-walled cavity over right apical region of lung. White blood cell (WBC) count did not reveal any abnormality. Erythrocyte sedimentation rate was 20 mm/hr and level of C-reactive protein was 11 mg/L.

Ultrasonography (USG) thorax showed an ill-defined hypoechoic lesion with few calcific specks in right upper lobe of lung. Fine needle aspiration cytology (FNAC) from the same was done and smears from the specimen stained with haematoxylin and eosin stain (H and E) and May Grunwald Giemsa (MGG) were negative for any evidence of either infection or malignancy.

High-resolution computed tomography (HRCT)-chest revealed: [Figure 1]
Figure 1: HRCT Chest showing thick walled cavity communicating with bronchus in the right lung

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  • Thick-walled cavity communicating with bronchus and peripheral lesion of right upper lobe with surrounding parenchymal changes
  • Large nodule with surrounding micronodules in left upper lobe.


Depending on the patient's complaints, systemic examination and radiological investigations, provisional diagnosis of fibrocavitatory pulmonary disease was made, suspected aetiologies being tuberculosis, fungal infection, metastatic lesion or a hydatid cyst.

Based on these findings, patient was started inj. cefotaxime 1 gm intravenous (IV) three times a day, and inj. theophyllin, inj. ranitidine, etc.

Bronchoalveolar lavage (BAL) fluid examination revealed pus cells, few gram-negative rods and septate fungal hyphae. Specimen was inoculated on Sabouraud dextrose agar. Culture grew Pseudomonas aeruginosa sensitive to aztreonam, cefepime, ceftazidime, levofloxacin, piperacillin, ticarcillin-clavulanic acid.

Culture on Sabouraud dextrose agar revealed moist, compact, orange to salmon colonies in 7 days [Figure 2] and [Figure 3].
Figure 2: Compact, folded colony of Acremonium species on Sabouraud dextrose agar with white, cottony hyphae

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Figure 3: Orange to salmon reverse on Sabouraud dextrose agar

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Microscopically, vegetative hyphae were hyaline and septate, narrow, slender. Conidiophores were solitary or branched, septate-bearing, phialidic conidiogenous cells. Conidia were ellipsoidal to short cylindrical, 1 celled, hyaline, accumulating in slimy heads, rarely as fragile chains, suggestive of Acremonium species [Figure 4].
Figure 4: Slide culture of Acremonium species showing hyaline branched septate hyaphae with septate branched conidiophores and conidia accumulating in slimy heads

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This was conveyed to the clinician. The antifungal susceptibility testing for Acremonium species was not done. BAL and sputum were negative for presence of acid fast bacilli. Patient's kidney function tests were found to be within normal range. The treatment was changed to inj. amphotericin B 11.5 mg IV once a day after a test dose. Inj. amphotericin B was continued for 14 days. No clinical improvement in the patient prompted a decision of surgical management with lobectomy. However, the patient refused surgery and was discharged with course of itraconazole 200 mg twice a day for 2 months, as an alternative to amphotericin B. After 6-8 weeks of itraconazole therapy, complete resolution of lung lesion (radiological) with symptomatic improvement was noted [Figure 5] and [Figure 6].
Figure 5: Chest X-ray showing right upper lobe lung lesion

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Figure 6: Chest X-ray showing resolving right upper lobe lung lesion after 8 weeks of itraconazole therapy

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Drug was continued for a total of 3 months. No recurrence of symptoms or radiological finding was noted after 6 months.


 ~ Discussion Top


The last 2 decades have witnessed a steady increase in the spectrum of hyaline fungi incriminated as opportunistic pathogens in immunocompromised patients. [1],[2],[3]

Many soil saprobes and plant pathogens with no obvious pathogenic potential have now emerged as etiologic agents under a variety of clinical conditions, thus posing new diagnostic and therapeutic challenges. [4] Acremonium is a large fungal genus that comprises approximately 150 species, most of them being saprophytes in soil and pathogens of plants.

Although Aspergillus and Fusarium are two major pathogenic filamentous genera, the role of Acremonium spp. is also being increasingly recognized in both localized and systemic infections. [1],[3],[5] Because Acremonium species are cosmopolitan in nature, they can also be encountered as contaminants. Thus, their isolation in culture requires cautious evaluation.

In immunocompetent individuals, arthritis, keratitis, endophthalmitis, mycetoma, onychomycosis or cutaneous infections are the most familiar forms of localized infections caused by Acremonium species. [1],[4]

On the other hand, in severely immunocompromised patients, Acremonium species may cause disseminated infections involving multiple organs. [4],[6],[7]

In one autopsy-proven study of invasive mould infections in cancer patients, 10% of the cases were caused by Acremonium spp.[2]

Acremonium is characterized by solitary, aculeate phialides or weakly branched conidiophores that arise from the vegetative filaments and bear either a wet cluster or dry chains of mostly one-celled spores (conidia). The filaments are sometimes bound together into ropes that are several cells in diameter. [5],[7] Acremonium shares numerous morphological characteristics with Fusarium; however, Fusarium spp. grow faster and have colonies with characteristic fluffy appearance.

Infections in humans develop following traumatic inoculation of fungus, with mycetoma and keratitis being the most common (Geyer et al., 2006; Read et al., 2000). Locally invasive infections, e.g. osteomyelitis (Keynan et al., 2007), sinusitis (Dueker et al., 2011), arthritis (Buchler et al., 2003), peritonitis (Khan et al., 2011; Sener et al., 2008) are also described.

Once diagnosed, invasive Acremonium infection is difficult to treat and the outcome is generally poor. Optimal treatment of Acremonium species infections is not well-defined, due to the limited number of reported cases and conflicting results obtained in different studies. [5],[7],[8],[9],[10]

In a review (Guarro et al., 1997), the authors used a microdilution broth method to compare the in vitro susceptibility, minimum inhibitory concentrations and minimum fungicidal concentrations of amphotericin B, miconazole, itraconazole, 5-fluorocytosine, fluconazole and ketoconazole for several isolates of Acremonium species. There was general resistance to most antifungals, excluding amphotericin B and ketoconazole. [7] Therefore, amphotericin B therapy, in combination with ketoconazole or another new azole or allylamine, is advocated. [5],[7],[8],[9],[10],[11] Despite this treatment regimen, there are still reports of clinical failure that results in death. [5],[8],[12],[13]

Though minimum inhibitory concentration for itraconazole has been reported to be high, our patient responded well to 200 mg twice a day dose given for 3 months.

In conclusion, the case described emphasize the need for clinical microbiology laboratories to be prepared to face the diagnosis of uncommon infectious diseases such as lung abscess by Acremonium and to enhance the awareness of surgeons and clinicians of this occurrence. Also, itraconazole therapy seems to be effective and is easier to administer over the prolonged course needed to cure Acremonium lung abscess in selected cases.

 
 ~ References Top

1.
Das S, Saha R, Dar SA, Ramachandran VG. Acremonium species: A review of the etiologic agents of emerging hyalohyphomycosis. Mycopathologia 2010;170:361-75.  Back to cited text no. 1
    
2.
Krcmery V Jr, Kunova E, Jesenska Z, Trupl J, Spanik S, Mardiak J, et al. Invasive mold infections in cancer patients: 5 years' experience with Aspergillus, Mucor, Fusarium and Acremonium infections. Support Care Cancer 1996;4:39-45.  Back to cited text no. 2
    
3.
Nucci M, Anaissie EJ. Emerging fungi. Infect Dis Clin North Am 2006;20:563-77.  Back to cited text no. 3
    
4.
Walsh TJ, Groll AH. Overview: Non-fumigatus species of Aspergillus: Perspectives on emerging pathogens in immunocompromised hosts. Curr Opin Investig Drugs 2001;21:366-7.  Back to cited text no. 4
    
5.
Fincher RM, Fisher JF, Lovell RD, Newman CL, Espinel-Ingroff A, Shadomy HJ. Infection due to the fungus Acremonium (Cephalosporium). Medicine (Baltimore, MD) 1991;70:398-409.  Back to cited text no. 5
    
6.
Guarro J, Del Palacio A, Gené J, Cano JJ, González CG. A case of colonization of a prosthetic mitral valve by Acremoniumstrictum. Rev Iberoam Micol 2009;26:146-8.  Back to cited text no. 6
    
7.
Guarro J, Gams W, Pujol I, Gené J. Acremonium species: New emerging fungal opportunists-in vitro antifungal susceptibilities and review. Clin Infect Dis 1997;25:1222-9.  Back to cited text no. 7
    
8.
Lau YL, Yuen KY, Lee CW, Chan CF. Invasive Acremoniumfalciforme infection in a patient with severe combined immunodeficiency. Clin Infect Dis 1995;20:197-8.  Back to cited text no. 8
[PUBMED]    
9.
Koç AN, Utas C, Oymak O, Sehmen E. Peritonitis due to Acremoniumstrictum in a patient on continuous ambulatory peritoneal dialysis. Nephron 1998;79:357-8.  Back to cited text no. 9
    
10.
Anadolu R, Hilmioglu S, Oskay T, Boyvat A, Peksari Y, Gürgey E. Indolent Acremoniumstrictum infection in an immunocompetent patient. Int J Dermatol 2001;40:451-3.  Back to cited text no. 10
    
11.
Nedret Koç A, Erdem F, Patiroglu T. Case report. Acremoniumfalciforme fungemia in a patient with acute leukaemia. Mycoses 2002;45:202-3.  Back to cited text no. 11
    
12.
Jeffrey WR, Hernandez JE, Zarraga AL, Oley GE, Kitchen LW. Disseminated infection due to Acremonium species in a patient with Addison›s disease. Clin Infect Dis 1993;16:170.  Back to cited text no. 12
[PUBMED]    
13.
Schell WA, Perfect JR. Fatal, disseminated Acremoniumstrictum infection in a neutropenic host. J Clin Microbiol 1996;34:1333-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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